The etiology of ischemic stroke affects prognosis, outcome, and management. Trials of therapies for patients with acute stroke should include measurements of responses as influenced by subtype of ischemic stroke. A system for categorization of subtypes of ischemic stroke mainly based on etiology has been developed for the Trial of Org 10172 in Acute Stroke Treatment (TOAST). A classification of subtypes was prepared using clinical features and the results of ancillary diagnostic studies. "Possible" and "probable" diagnoses can be made based on the physician9s certainty of diagnosis. The usefulness and interrater agreement of the classification were tested by two neurologists who had not participated in the writing of the criteria. The neurologists independently used the TOAST classification system in their bedside evaluation of 20 patients, first based only on clinical features and then after reviewing the results of diagnostic tests. The TOAST classification denotes five subtypes of ischemic stroke: 1) large-artery atherosclerosis, 2) cardioembolism, 3) small-vessel occlusion, 4) stroke of other determined etiology, and 5) stroke of undetermined etiology. Using this rating system, interphysician agreement was very high. The two physicians disagreed in only one patient. They were both able to reach a specific etiologic diagnosis in 11 patients, whereas the cause of stroke was not determined in nine. The TOAST stroke subtype classification system is easy to use and has good interobserver agreement. This system should allow investigators to report responses to treatment among important subgroups of patients with ischemic stroke. Clinical trials testing treatments for acute ischemic stroke should include similar methods to diagnose subtypes of stroke.

Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment

Background: Antiplatelet agents are the mainstay for secondary prevention of non-cardioembolic stroke. This systematic review examined the safety and efficacy of

/pdf/aspirin-plus-clopidogrel-as-secondary-prevention-after-1lwk28c5lr.pdf

Aspirin plus Clopidogrel as Secondary Prevention after Stroke or Transient Ischemic Attack: A Systematic Review and Meta-Analysis

I have developed "tennis elbow" from lugging this book around the past four weeks, but it is worth the pain, the effort, and the aspirin. It is also worth the (relatively speaking) bargain price. Including appendixes, this book contains 894 pages of text. The entire panorama of the neural sciences is surveyed and examined, and it is comprehensive in its scope, from genomes to social behaviors. The editors explicitly state that the book is designed as "an introductory text for students of biology, behavior, and medicine," but it is hard to imagine any audience, interested in any fragment of neuroscience at any level of sophistication, that would not enjoy this book. The editors have done a masterful job of weaving together the biologic, the behavioral, and the clinical sciences into a single tapestry in which everyone from the molecular biologist to the practicing psychiatrist can find and appreciate his or

Principles of Neural Science

Background and Purpose—The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audienc...

/pdf/guidelines-for-the-early-management-of-patients-with-acute-19udbft6e7.pdf

Guidelines for the Early Management of Patients With Acute Ischemic Stroke A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

The impact of nonrheumatic atrial fibrillation, hypertension, coronary heart disease, and cardiac failure on stroke incidence was examined in 5,070 participants in the Framingham Study after 34 years of follow-up. Compared with subjects free of these conditions, the age-adjusted incidence of stroke was more than doubled in the presence of coronary heart disease (p less than 0.001) and more than trebled in the presence of hypertension (p less than 0.001). There was a more than fourfold excess of stroke in subjects with cardiac failure (p less than 0.001) and a near fivefold excess when atrial fibrillation was present (p less than 0.001). In persons with coronary heart disease or cardiac failure, atrial fibrillation doubled the stroke risk in men and trebled the risk in women. With increasing age the effects of hypertension, coronary heart disease, and cardiac failure on the risk of stroke became progressively weaker (p less than 0.05). Advancing age, however, did not reduce the significant impact of atrial...

https://www.ahajournals.org/doi/pdf/10.1161/01.STR.22.8.983

Atrial fibrillation as an independent risk factor for stroke: the Framingham Study.

We present epidemiologic, etiologic, and clinical data for 1,000 consecutive patients with a first stroke (cerebral infarction or hemorrhage) admitted to the Centre Hospitalier Universitaire Vaudois since 1982. The patients were evaluated using a standard protocol of tests (computed tomography, Doppler ultrasonography, and electrocardiography in all patients, as well as angiography and specific cardiac investigations in selected patients). Each case was coded prospectively into a computerized registry. We believe that the Lausanne Stroke Registry is the first registry with complete computed tomography and Doppler ultrasonography data on all patients, which allows correlation between clinical findings, presumed etiology, and stroke location. Although the Lausanne Stroke Registry is not population-based, it gives a good estimate of the stroke-related problems in patients admitted to a primary-care center since our hospital is the sole acute-care facility for stroke in the Lausanne area.

The Lausanne Stroke Registry: analysis of 1,000 consecutive patients with first stroke.

• Because the cause and prognosis of ischemic stroke in adults younger than 30 years of age are not known, we observed 41 such patients (26 females and 15 males) using a standard protocol of investigations, including cerebral angiography and echocardiography. Mitral valve prolapse and arterial dissection accounted for 51% of infarcts, migrainous infarction was the likely cause in 15% of infarcts, and uncommon causes accounted for 34% of infarcts. Atherosclerosis played a role in only two patients. Two thirds of the women were taking oral contraceptives, which may have been the primary cause of stroke in one woman who had recurrent venous thromboses followed by thrombosis of the aortic arch. Three patients (7.3%) died of acute causes. During follow-up (mean, 46 months), the annual incidence of death (0.7%) and recurrent stroke (0.7%) was low. Eighty-one percent of the survivors could return to work. We conclude that cerebral angiography and echocardiography are indicated in all adults younger than 30 years of age. After the acute phase of stroke, prognosis is reasonable.

Ischemic stroke in adults younger than 30 years of age. Cause and prognosis.

Hyperkinetic movement disorders during and after acute stroke: The Lausanne Stroke Registry

Bilateral watershed (WS) infarction at the borderzone of the middle cerebral artery territory are typically related to severe hypotensive events. Unilateral WS infarctions have sometimes been reported in occlusion of the ipsilateral internal carotid artery (ICA), but their pathogenesis and prognostic implications are poorly known. Twenty-six of 154 (17%) consecutive patients with ICA occlusion had a computed tomography-proved ipsilateral WS infarct. Severe active heart disease with hypotension and syncope (p less than 0.0001), severe contralateral ICA disease (p less than 0.001), and elevated venous hematocrit values (p less than 0.001) related to heavy smoking were more frequent in the patients with WS infarction than in other patients. Delayed infarctions in the territory of the main branches of the middle cerebral artery distal to the ICA occlusion correlated with a visible stump or emboligenic changes (ulcerated or irregular stenosis) on the collateral channels, but this was not true for delayed WS infarctions. These findings suggest that most of the WS infarctions were hemodynamic. The patients with WS infarct had a higher death rate (9.9% per year) than did the patients without WS infarct (2.3% per year), suggesting that heart disease should be particularly closely managed in patients with WS infarctions. As WS infarctions were the most frequent type of infarction distal to an occluded ICA, appropriate treatment of all potential causes of systemic hemodynamic disturbances may be crucial in the long-term management of patients with ICA occlusion.

Borderzone infarctions distal to internal carotid artery occlusion: prognostic implications.

The study of 3 personal cases and 5 published cases of unilateral infarct limited to the territory of the tuberothalamic artery suggests that this syndrome should be differentiated from the other thalamic syndromes. The onset is usually sudden, with moderate contralateral weakness. Sensory changes may be present but remain mild. The patients are apathetic, show perseveration and may be disoriented. In left-sided infarcts, transcortical aphasia, verbal and visual memory impairment and sometimes acalculia are found. In right-sided infarcts, hemispatial neglect, visual memory impairment and disturbed visuospatial processing are common. A decreased level of consciousness, disturbed ocular movements, severe motor weakness and delayed abnormal movements do not occur. Involvement of the ventral lateral and dorsomedial nucleus with sparing of the intralaminar nuclei, posterolateral formation and upper midbrain may explain this picture. The fact that the tuberothalamic artery arises from the posterior communicating artery, which often receives its supply from the carotid system, further justifies considering unilateral tuberothalamic infarcts as a syndrome.

https://www.ahajournals.org/doi/pdf/10.1161/01.STR.17.3.434

The syndrome of unilateral tuberothalamic artery territory infarction.

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